A 28-year-old woman is treated with high-dose prednisone for severe lupus nephritis. Several hours after therapy is initiated, she becomes very agitated and delusional. Blood pressure is 130/70 mm Hg and heart rate is 110/min. A basic metabolic profile, complete blood cell (CBC) count, and urinalysis are obtained. The CBC differential is expected to show an increase in which of the following as a result of this patient's therapy?

Question

A 28-year-old woman is treated with high-dose prednisone for severe lupus nephritis.  Several hours after therapy is initiated, she becomes very agitated and delusional.  Blood pressure is 130/70 mm Hg and heart rate is 110/min.  A basic metabolic profile, complete blood cell (CBC) count, and urinalysis are obtained.  The CBC differential is expected to show an increase in which of the following as a result of this patient's therapy?

Quizplus · Accepted Answer

11ec160b_37a7_6044_9249_09dec3eabc2b_MD0001_00 As a result of their immunosuppressive effects, corticosteroids such as prednisone have been used to treat many autoimmune and inflammatory conditions, including systemic lupus erythematous. However, corticosteroid use can lead to a number of adverse effects. High doses can sometimes cause corticosteroid-induced psychosis (confusion, hallucinations), as seen in this patient; hypoalbuminemia is a risk factor, and the neuropsychiatric symptoms typically resolve with discontinuation of therapy. Corticosteroid receptors also have widespread physiologic effects, including those on circulating leukocytes and vascular endothelial cells. Neutrophil counts increase following administration of the drug as a result of "demargination" of neutrophils previously attached to the vessel wall. Therefore, neutrophil recruitment to fight infection in tissues is decreased, potentially contributing to increased infection risk. (Choice A) Corticosteroids reduce basophil count, which decreases local inflammatory responses by preventing histamine release. (Choice B) Eosinophil counts decrease significantly with administration of corticosteroids (an effect previously used as the basis for a bioassay for corticosteroids). These drugs are used in allergic conditions as they reduce the eosinophil count and therefore the release of mediators from the eosinophils. (Choice C) Corticosteroids reduce peripheral lymphocyte counts within minutes as a result of inhibition of immunoglobulin synthesis, stimulation of lymphocyte apoptosis, and lymphocyte redistribution (from the intravascular compartment to the spleen, lymph nodes, and bone marrow). T lymphocyte counts are typically reduced to a greater degree than B lymphocyte counts. (Choice D) Corticosteroids inhibit peripheral extravasation of monocytes and macrophages and decrease antigen presentation by macrophages and dendritic cells. Blood monocyte levels drop after corticosteroid administration due to redistribution to lymphoid tissues. Educational objective: The acute effects of corticosteroids on the white blood cell count include an increased neutrophil count and decreased lymphocyte, monocyte, basophil, and eosinophil counts. The increase in the neutrophil count results from "demargination" of neutrophils previously attached to the vessel wall. __________ References: A mechanism for the antiinflammatory effects of corticosteroids: the glucocorticoid receptor regulates leukocyte adhesion to endothelial cells and expression of endothelial-leukocyte adhesion molecule 1 and intercellular adhesion molecule 1. (http://www.ncbi.nlm.nih.gov/pubmed/1279685)

A 28-Year-Old Woman Is Treated with High-Dose Prednisone for Severe